Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, March 31, 1991 TAG: 9104020091
SECTION: VIRGINIA PAGE: A/1 EDITION: METRO
SOURCE:
DATELINE: CATAWBA LENGTH: Long
Woodall, 67, sometimes talks to her mother and older brother, both dead. Years ago, she talked to Jesus, but he threatened to kill her.
"I'm thinking about going home soon," she says. "Maybe today, maybe tomorrow." She plans to leave in a shiny new black Cadillac. She can't drive, but that's OK. One of her imaginary daughters knows how.
For 2 1/2 years, Woodall's home has been Catawba hospital's fourth floor, a locked ward that patients seldom leave. This is a floor where most patients need help with walking and feeding and the simplest of activities. Many are in wheelchairs. Many of the hospital's sickest patients - mentally and physically - live on this floor, which is called a long-term rehabilitation unit.
While Catawba's goal is to stabilize, treat and return patients to less restrictive settings, some will never make it.
It is uncertain whether Gladys Woodall would be able to survive outside a state mental facility. "She'll always have signs of a chronic illness," staff psychiatrist Dave Sheiderer says.
Woodall's problems began in 1943 when she was 19. A marriage to an Army Air Force serviceman lasted only two weeks. A psychiatrist began treating her for "nerves," says an older brother who lives in New York. Woodall lived at home with her mother and continued her job at a furniture factory until 1958, when her nerves got the best of her, her brother says.
Ten years later, Woodall was committed to Western State Hospital after "going off the deep end," her brother, Carroll, says. Woodall was seclusive, confused, excited, fearful, talkative and heard voices of religious figures. She stayed a few months and was sent back home. Her diagnosis was schizophrenia.
Since then, Woodall has been in and out of mental hospitals, nursing homes and hospital psychiatric units before coming to Catawba. Doctors now believe that depression is a major part of Woodall's problem and have been able to stabilize her mood swings with lithium and an antipsychotic drug.
Whether public mental hospitals will always be needed to treat long-term patients like Woodall is a subject of intense debate.
"It's unrealistic to expect everyone will be able to leave state hospitals," University of Virginia psychiatry professor Ivo Abraham says. "We have to accept the fact that some people are so ill they need the most intensive care possible."
Dr. Barry Lebowitz, a psychiatrist with the National Institute of Mental Health, agrees. "These are sick, old people. They can't be cared for in a community facility."
Yet some states believe large, public hospitals are a thing of the past. Vermont hopes to completely shut down its single remaining mental hospital. In the past three years, the average census at that facility, which once housed 1,500 patients, has been cut from 200 to 100. This has been done largely by beefing up the services offered in the state's 10 regional community health centers.
Will there be a core group of mental patients in Vermont who can be treated only at the state hospital? "We don't know," says John Pierce, assistant director of the state's mental health division. "The jury is still out."
It's wrong to focus the debate about mental health care for the elderly only on state hospitals, says Dr. Barry Fogel, a Brown University psychiatrist who heads a task force of the American Psychiatric Association looking at the role of public mental health facilities in caring for the elderly.
"The issue is not must we have state hospitals, but can we allow states to weasel out of their responsibility to take care of this frail and vulnerable population?" Fogel says.
For 20 years, Fogel and others say, a big factor in the drastic drop of elderly patients at public hospitals was the dramatic rise of nursing homes and adult homes. Many patients simply traded life in a public institution for life in a private facility.
But nursing homes and adult homes aren't able or don't want to take on today's population of elderly state hospital residents, says Dr. Chris Colenda, director of geriatric psychiatric education at Bowman Gray school of medicine at Wake Forest University. "What's left in the state hospitals are the sickest patients. They are the most difficult to take care of."
Their care also is expensive. Fogel says it often will be more economical for states to rid themselves of the burden of large and often run-down public institutions and simply contract services with private hospitals and health care workers.
Maintaining the bricks and mortar of large facilities and paying state employees - who may have inflexible work rules and who often have considerable clout with state legislatures - can be "like maintaining a yacht - it's a bottomless pit," Fogel says.
As a consultant to mental health officials in Maine, Fogel has recommended that the state subsidize nursing homes and psychiatric units at private hospitals for the cost of treating the most seriously ill elderly mental patients. He's also suggested that each elderly state patient be assigned a private psychiatrist who would get an annual retaining fee to treat former state hospital patients.
Such a system, Fogel thinks, ultimately would be cheaper than operating state facilities.
A similar approach has been suggested in Maryland by Dr. Barbara Burns, a professor of medical psychology at Duke University. Many elderly patients in state mental facilities need around-the-clock care, Burns says. Nursing homes could provide that care, she adds, but only if they are given additional money to cover the costs.
"There is hardly any psychiatric care for this population in nursing homes now," Burns says. One study, she notes, estimates there are nearly 800,000 elderly in nursing homes who need psychiatric treatment - more than 15 times the 50,000 in state and private mental hospitals. Yet only 5 percent of that elderly nursing home population gets treatment from mental health professionals, the study says.
"What they get instead of professional help is a lot of drugs prescribed by a general practitioner," Burns says.
Some of Virginia's 210 nursing homes have special Alzheimer's units to care for patients with dementia. But the vast majority of the state's nearly 26,000 nursing home beds are geared to providing medical - not psychiatric - care.
About 4,000 of the more than 20,000 residents in Virginia's 450 adult homes are mentally ill, yet several state reports in the past decade said these homes lacked the specialized staff needed to give even minimum psychiatric care.
Burns believes states should provide other treatment for the elderly through community-based mental health centers. Federal legislation passed in 1963 requires each state to set up regional community service boards to provide services for the mentally ill. But these boards generally have been underfunded and overwhelmed.
Mobile psychiatric treatment teams that treat the elderly at home and special group housing are just a couple of the community-based programs Burns wants to see implemented. But operating such programs costs money at a time states are trying to cut spending.
Ideally, Virginia's mental health system should have used the $3.2 million saved by closing the Western State geriatric unit to beef up services for the elderly through the state's 40 community service boards, mental health commissioner King Davis says.
"But in these economic times we are in, we basically have to use the savings to offset the budget shortfall," Davis says.
The community service boards got a boost with an additional $64 million in the 1988-90 budget of Gov. Gerald Baliles. The boards now receive about $155 million annually from the state, but that is still less than half of $368 million earmarked for mental hospitals and other facilities.
None of the $64 million influx under Baliles was targeted for the elderly mentally ill, although they did benefit indirectly. Mental Health Services of the Roanoke Valley, the community service board for this area, was able to add another case manager to work with elderly living in the community. The board added six case workers for younger adults.
For the 1990-1992 budget, community service boards proposed specialized programs to serve 545 elderly persons with serious mental illness and 1,120 elderly substance abusers. The programs were not funded.
Davis warns that, in the next few years, the legislature will be forced to confront a lingering and expensive problem with the mental health system: old facilities.
Restoring Piedmont Geriatric Hospital, a former tuberculosis sanatorium in Nottoway County that is now a 210-bed mental health facility, will cost $27 million, Davis says.
Noting that most of the system's buildings are aging, Davis adds, "The question for the commonwealth this decade is whether it is in fact prudent to spend millions of dollars to restore aging facilities in an era in which we are going to community-based care? Is there a better utilization of the funds?"
It would be a mistake to continue to close state geriatric mental facilities, says Bowman Gray psychiatrist Colenda, who once was a consultant at Piedmont as a member of the Medical College of Virginia faculty.
"Some say community-based care for the elderly is cheaper than hospital-based care. That hypothesis might not be true," he says.
Colenda envisions state facilities like Catawba and Piedmont serving as regional resources for care of the elderly, using the expertise of state medical schools and working with community-based programs.
That vision could be a reality soon in the Roanoke Valley. Two psychiatrists from the University of Virginia - one at Catawba and one at Roanoke Memorial hospital - are working to establish a residency program in psychiatry. If plans go as expected, as many as eight UVa residents will come to the valley part of each year to care for patients at Catawba, Roanoke Memorial, the Salem VA hospital and outpatient clinics operated by the local community service board.
Such cooperative programs will be necessary to prevent an ever-increasing elderly population from swamping the mental health system, UVa's Abraham says. State hospitals, he says, will continue to play a vital role in geriatric psychiatry.
"That is what concerns so many people about the state's decision to close the Western State geriatric unit," Abraham says. "We're talking about a population that is only going to increase in size."
by CNB